jdd111168
Networker
I work for five allergist. One of my Doctors codes most of his new patient office visits' as a 99204. By my audits they are 99203 at most. The Exam portion is what's bringing the level down. If you were to audit the following what level exam do you get??? I just need to make sure I am not missing anything. We use 97 Guidelines. Thank in advance! 
Vitals*3/2/2015 9:24 AM
3/2/2015 9:23 AM
*Weight: 129.8 lb *Height: 60 in
Height was reported by patient.
*Body Surface Area: 1.58 m? *Body Mass Index: 25.35 kg/m?
*Temp.: 98.4? F (Tympanic)* *Pulse: 97 (Regular)* *Resp.: 16 (Unlabored)* *P.OX: 94% (Room air)
*BP: 115/76*** (Sitting, Left Arm, Standard)
*
Physical Exam*
The physical exam findings are as follows:
*
General*
General Appearance*- Cooperative and Well groomed. Posture*- Normal posture. Gait*- Normal. Hydration*- Well hydrated.
Integumentary*
Global Assessment:*Upon inspection and palpation of skin surfaces of the - Head/Face: no rashes, ulcers, lesions or evidence of photo damage. No palpable nodules or masses, Neck: no visible lesions or palpable masses, Right upper extremity: no lesions or rashes. No evidence of photo damage, Left upper extremity: no lesions or rashes. No evidence of photo damage and Distribution of scalp and body hair is normal.
General Characteristics:*Overall examination of the patient's skin reveals* - no rashes. Color*- normal coloration of skin. Skin Moisture*- normal skin moisture. Hair Distribution and Texture - normal distribution of scalp and body hair, with normal hair texture.
Head and Neck
Face*
Global Assessment*- atraumatic.
Neck*
Global Assessment*- supple. non-tender and no lymphadenopathy.
Trachea*- midline.
Thyroid*
Gland Characteristics*- normal size and consistency. non-tender.
Eye*
Eyeball*- Bilateral*- Normal. Sclera/Conjunctiva*- Bilateral*- Normal. Pupil*- Bilateral*- Normal, Equal, Regular and Round. No Fixed.
ENMT
Ears*
Pinna*- Bilateral*- Normal. no edema and no erythema of auricle. External Auditory Canal*- Bilateral*- no cerumen impaction noted, no drainage observed, no edema noted in EAC, no purulent discharge noted and no tenderness noted.
Otoscopic Exam:*Tympanic Membrane*- Bilateral*- no bulging noted, no inflammation observed, no retraction of TM observed, no scarring observed and no evidence of tympanosclerosis.
Nose and Sinuses*
Inspection of the nares - Bilateral*- normal respiration, quiet respiration and no mucus present . Nasal Mucosa*- Bilateral*- no bleeding noted, no congestion observed and no ulcerations observed.
Nasal Septum:*Bony Septum*- no bleeding noted, no inflammation of surrounding mucosa, no perforation noted and no scarring present.
Turbinates:*Inferior*- Bilateral*- not enlarged and no inflammation noted. Maxillary Sinuses*- Bilateral*- no tenderness observed.
Mouth and Throat*
Lips:*Upper Lip*- not dry. Lower Lip*- no dryness observed.
Nasopharynx*- no congestion noted, no discharge present and no mucoid material present in nasopharynx.
Oral Cavity/Oropharynx:*Teeth*- no missing teeth. Gingiva*- no bleeding observed, no hypertrophy noted and no inflammation present. Hard Palate*- no erythema noted, no perforation noted and no petechiae noted. Soft Palate*- no abnormal motion on phonation, no asymmetry noted and no erythema noted. Tongue*- not enlarged, not fissured, no evidence of paralysis and no white patches present. Oral Mucosa*- no discoloration noted and no dryness noted. Oropharynx*- no evidence of airway distress observed, no uvular edema is observed, no edema of posterior pharyngeal walls observed and there is no swelling of the pharyngeal mucosa.
Tonsils:*Characteristics*- Bilateral*- no erythema noted and no hypertrophy.
Floor of Mouth*- no edema observed and no hyperkeratosis observed.
Chest and Lung Exam*
Inspection:*Shape*- Symmetric. Movements*- Symmetrical. Accessory muscles*- No use of accessory muscles in breathing.
Auscultation:*
Breath sounds:*- Normal and - Clear.
Adventitious sounds:*- No Adventitious sounds.
Cardiovascular*
Cardiovascular examination reveals* - normal heart sounds, regular rate and rhythm with no murmurs.
Lymphatic
Head & Neck*
Submandibular Nodes:*
Bilateral:*Size*- Note: no enlarged lymph node* Overlying skin*- Normal.
Vitals*3/2/2015 9:24 AM
3/2/2015 9:23 AM
*Weight: 129.8 lb *Height: 60 in
Height was reported by patient.
*Body Surface Area: 1.58 m? *Body Mass Index: 25.35 kg/m?
*Temp.: 98.4? F (Tympanic)* *Pulse: 97 (Regular)* *Resp.: 16 (Unlabored)* *P.OX: 94% (Room air)
*BP: 115/76*** (Sitting, Left Arm, Standard)
*
Physical Exam*
The physical exam findings are as follows:
*
General*
General Appearance*- Cooperative and Well groomed. Posture*- Normal posture. Gait*- Normal. Hydration*- Well hydrated.
Integumentary*
Global Assessment:*Upon inspection and palpation of skin surfaces of the - Head/Face: no rashes, ulcers, lesions or evidence of photo damage. No palpable nodules or masses, Neck: no visible lesions or palpable masses, Right upper extremity: no lesions or rashes. No evidence of photo damage, Left upper extremity: no lesions or rashes. No evidence of photo damage and Distribution of scalp and body hair is normal.
General Characteristics:*Overall examination of the patient's skin reveals* - no rashes. Color*- normal coloration of skin. Skin Moisture*- normal skin moisture. Hair Distribution and Texture - normal distribution of scalp and body hair, with normal hair texture.
Head and Neck
Face*
Global Assessment*- atraumatic.
Neck*
Global Assessment*- supple. non-tender and no lymphadenopathy.
Trachea*- midline.
Thyroid*
Gland Characteristics*- normal size and consistency. non-tender.
Eye*
Eyeball*- Bilateral*- Normal. Sclera/Conjunctiva*- Bilateral*- Normal. Pupil*- Bilateral*- Normal, Equal, Regular and Round. No Fixed.
ENMT
Ears*
Pinna*- Bilateral*- Normal. no edema and no erythema of auricle. External Auditory Canal*- Bilateral*- no cerumen impaction noted, no drainage observed, no edema noted in EAC, no purulent discharge noted and no tenderness noted.
Otoscopic Exam:*Tympanic Membrane*- Bilateral*- no bulging noted, no inflammation observed, no retraction of TM observed, no scarring observed and no evidence of tympanosclerosis.
Nose and Sinuses*
Inspection of the nares - Bilateral*- normal respiration, quiet respiration and no mucus present . Nasal Mucosa*- Bilateral*- no bleeding noted, no congestion observed and no ulcerations observed.
Nasal Septum:*Bony Septum*- no bleeding noted, no inflammation of surrounding mucosa, no perforation noted and no scarring present.
Turbinates:*Inferior*- Bilateral*- not enlarged and no inflammation noted. Maxillary Sinuses*- Bilateral*- no tenderness observed.
Mouth and Throat*
Lips:*Upper Lip*- not dry. Lower Lip*- no dryness observed.
Nasopharynx*- no congestion noted, no discharge present and no mucoid material present in nasopharynx.
Oral Cavity/Oropharynx:*Teeth*- no missing teeth. Gingiva*- no bleeding observed, no hypertrophy noted and no inflammation present. Hard Palate*- no erythema noted, no perforation noted and no petechiae noted. Soft Palate*- no abnormal motion on phonation, no asymmetry noted and no erythema noted. Tongue*- not enlarged, not fissured, no evidence of paralysis and no white patches present. Oral Mucosa*- no discoloration noted and no dryness noted. Oropharynx*- no evidence of airway distress observed, no uvular edema is observed, no edema of posterior pharyngeal walls observed and there is no swelling of the pharyngeal mucosa.
Tonsils:*Characteristics*- Bilateral*- no erythema noted and no hypertrophy.
Floor of Mouth*- no edema observed and no hyperkeratosis observed.
Chest and Lung Exam*
Inspection:*Shape*- Symmetric. Movements*- Symmetrical. Accessory muscles*- No use of accessory muscles in breathing.
Auscultation:*
Breath sounds:*- Normal and - Clear.
Adventitious sounds:*- No Adventitious sounds.
Cardiovascular*
Cardiovascular examination reveals* - normal heart sounds, regular rate and rhythm with no murmurs.
Lymphatic
Head & Neck*
Submandibular Nodes:*
Bilateral:*Size*- Note: no enlarged lymph node* Overlying skin*- Normal.